title: The changing nature of death on the trauma service.
abstract: BACKGROUND
  Recent innovations in care have improved survival following injury. Coincidentally, the population of elderly injured patients with preexisting comorbidities has increased. We hypothesized that this increase in elderly injured patients may have combined with recent care innovations to alter the causes of death after trauma.
  
  
  METHODS
  We reviewed demographics, injury characteristics, and cause of death of in-hospital deaths of patients admitted to our Level I trauma service from 2000 through 2011. Cause of death was classified as acute hemorrhagic shock; severe traumatic brain injury or high spinal cord injury; complications of preexisting medical condition only (PM); survivable trauma combined with complications of preexisting medical condition (TCoM); multiple-organ failure, sepsis, or adult respiratory distress syndrome (MOF/S/ARDS), or trauma not otherwise categorized (e.g., asphyxiation). Major trauma care advances implemented on our service during the period were identified, and trends in the causes of death were analyzed.
  
  
  RESULTS
  Of the 27,276 admissions, 819 (3%) eligible nonsurvivors were identified for the cause-of-death analyses. Causes of death were severe traumatic brain injury or high spinal cord injury at 44%, acute hemorrhagic shock at 28%, PM at 11%, TCoM at 10%, MOF/S/ARDS at 2%, and trauma not otherwise categorized at 5%. Mean age at death increased across the study interval (range, 47-57 years), while mean Injury Severity Score (ISS) decreased (range, 28-35). There was a significant increase in deaths because of TCoM (3.3-20.9%) and PM (6.7-16.4%), while deaths caused by MOF/S/ARDS decreased from 5% to 0% by 2007. Compared with year 2000, the annual adjusted mortality rate decreased consistently starting in 2009, after the 2002 to 2007 adoption of four major trauma practice guidelines.
  
  
  CONCLUSIONS
  Mortality caused by preexisting medical conditions has increased, while markedly fewer deaths resulted from the complications of injury. Future improvements in outcomes will require improvement in the management of elderly trauma patients with comorbid conditions.
authors.affiliation: Trauma Service, Scripps Mercy Hospital, San Diego, California 92103, USA.
authors.forename: Jessica E
authors.initials: JE
authors.lastname: Kahl
authors.forename: Richard Y
authors.initials: RY
authors.lastname: Calvo
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Sise
authors.forename: C Beth
authors.initials: CB
authors.lastname: Sise
authors.forename: Jonathan F
authors.initials: JF
authors.lastname: Thorndike
authors.forename: Steven R
authors.initials: SR
authors.lastname: Shackford
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000401:mortality; D002140:California / Q000453:epidemiology; D002423:Cause of Death; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology / Q000401:mortality; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000401:mortality; D012189:Retrospective Studies; D018805:Sepsis / Q000209:etiology / Q000401:mortality; D012771:Shock, Hemorrhagic / Q000209:etiology / Q000401:mortality; D013119:Spinal Cord Injuries / Q000401:mortality; D014193:Trauma Centers / Q000706:statistics & numerical data*; D014947:Wounds and Injuries / Q000150:complications / Q000401:mortality*